Basic Information
| Provider Information | |||||||||
| NPI: | 1114383023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST ORTHOPEDIC SPECIALISTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 BOWDEN RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Practice Location | |||||||||
| Address1: | 15255 MAX LEGGETT PKWY | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322187273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2016 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | DUFFY | ||||||||
| AuthorizedOfficialFirstName: | GAVAN | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9046340640 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.